Documenting and Coding Strep Throat – A Common Winter Ailment

by | Published on Jan 14, 2020 | Medical Coding

Documenting and Coding Strep Throat
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A common winter ailment, strep throat causes inflammation and pain in the throat. Caused by Group A Streptococcus bacteria or Streptococcus pyogenes, the condition can affect people of all age groups. Also called Streptococcal pharyngitis, this condition is more common in children in the age group of 5 – 15. Strep throat is highly contagious and usually spreads through direct person-to-person contact. Sneezing and coughing can spread the infection from one person to another. People can also get infected by touching surfaces such as a doorknob, kitchen utensils, or bathroom objects that an infected person had previously touched. Most cases of strep throat are not serious as the infected person’s condition generally improves within 3-7 days without treatment. If left untreated, strep throat can cause severe complications such as kidney inflammation or rheumatic fever. Rheumatic fever can lead to painful and inflamed joints, a specific type of rash, or heart valve damage. Physicians treating patients suffering from this winter ailment should correctly document the medical services provided. Opting for billing and coding services from a reputable physician billing company can help simplify the documentation process.

Here is a detailed overview of this winter condition and its ICD-10 codes.

There are different signs and symptoms associated with strep throat. The severity of symptoms may vary from one person to another, and depend upon the age of the person infected. In some cases, people may experience mild symptoms like a sore throat. These symptoms typically develop within five days of exposure to the strep bacteria. Some of the other symptoms include – throat pain, painful swallowing, headache, body ache, fever, rashes, red and swollen tonsils; swollen, tender lymph nodes in the neck and nausea or vomiting (especially in younger children). Adults with this condition may experience milder symptoms that may not prompt a medical evaluation unless an exposure history to strep throat is known.

How Is Strep Throat Diagnosed and Treated?

Early testing and correct treatment are essential. Diagnosis of this condition generally begins with a detailed physical examination wherein the physician may look for possible signs and symptoms of this condition.

Physicians will generally examine the throat and check for signs of inflammation. They may also check the patient’s neck for swollen lymph nodes and ask about other symptoms. In case the physicians suspect strep throat infection, they may do a rapid strep test (rapid antigen test) to check whether the patient’s sore throat is caused by a strep infection or another type of bacteria or germs. They may swab the back of your throat with a long cotton swab to collect a sample which is then sent to a lab to look for signs of bacteria. This test can detect strep bacteria in minutes by looking for substances (antigens) in the throat. If the test is negative but your doctor still suspects strep, he or she might do a throat culture.

As the throat condition is a bacterial infection, physicians may prescribe antibiotics as part of the treatment as these medications inhibit the spread of bacteria and infections. Penicillin and amoxicillin are the most common medications given for a strep infection. If taken within 48 hours of the onset of the illness, antibiotics can reduce the severity and duration of symptoms as well as the risk of complications, and the chance of infection spreading to others. However, it is important for patients to finish the course of antibiotic treatment to kill the infection completely. Stopping the course of medications early can lead to recurrences and serious complications such as rheumatic fever or kidney inflammation. In addition to this, over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) may be prescribed to relieve common symptoms like throat pain, fever, headache and rashes.

Billing and coding for this infectious disorder could be complex as there are several rules related to reporting the condition correctly. Physicians need to correctly diagnose the symptoms of strep throat and report it using the correct codes. Medical billing outsourcing services provided by reputable medical billing companies can help physicians use the correct codes for their billing purposes. ICD-10 codes for diagnosing this condition include –

  • J02 – Acute pharyngitis
  • J02.0 – Streptococcal pharyngitis
  • J02.8 – Acute pharyngitis due to other specified organisms
  • J02.9 – Acute pharyngitis, unspecified
  • J31.1 – Chronic nasopharyngitis
  • J31.2 – Chronic pharyngitis

There is no vaccine available that prevents strep throat. One of the best ways to avoid strep infection is regular hand washing and covering the mouth when coughing. It is recommended not to share personal items (like pillows, towels, sheets or other utensils) with someone who has strep throat. Preventive measures that reduce the discomfort associated with throat infection include rest, drinking plenty of warm fluids, using a cool-mist humidifier, staying away from irritants, consuming soothing foods and gargling with warm salt water.

Medical coding tasks can be outsourced to a reliable medical billing and coding company that offers the services of AAPC-certified coding specialists to ensure correct and timely medical billing and claims submission.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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